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Cho SH, Kim HS, Park BS, Son GM, Park SB, Yun MS. Usefulness of intraoperative colonoscopy and synchronous scoring system for determining the integrity of the anastomosis in left-sided colectomy: a single-center retrospective cohort study. BMC Surg 2025; 25:116. [PMID: 40140991 PMCID: PMC11948651 DOI: 10.1186/s12893-025-02836-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 11/08/2024] [Indexed: 03/28/2025] Open
Abstract
OBJECTIVES The aim of this study is to evaluate the utilization of intraoperative colonoscopy (IOC) for determining the integrity of the anastomosis and to establish an IOC scoring system. METHODS A retrospective cohort study was conducted from January 2021 to June 2024, we analyzed the clinical data of 160 patients registered in a database who underwent laparoscopic left-sided colectomy at Pusan National University Yangsan Hospital. IOC was performed on all patients, and Mucosal color (MC), stapled line bleeding (BL), proximal redundancy (PR), and bowel preparation (BP) were evaluated and scored as variables. Logistic regression analysis was used to evaluate risk factors for anastomotic leakage (AL) and Cohen's kappa was applied to assess the reproducibility of the evaluation. RESULTS Of 160 patients, 10 (6.25%) experienced AL. All the IOC variables had kappa values of 0.8 or higher, indicating good agreement. The logistic regression analysis revealed significant differences in the MC 2 (P = 0.017, OR 12.86), PR 2 (P = 0.001, OR 27.64), BP 2 (p = 0.016, OR 10.50) PR 2 score (P = 0.016, OR 10.50) and the sum of the scores (p = 0.001, OR 3.51). CONCLUSION IOC can be performed as a reference procedure to assess the integrity of the anastomosis during left-sided colorectal surgery.
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Affiliation(s)
- Sung Hwan Cho
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, 20 Geumo-Ro, Yangsan-Si, Gyeongsangnam-Do, 50612, Republic of Korea
| | - Hyun Sung Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, 20 Geumo-Ro, Yangsan-Si, Gyeongsangnam-Do, 50612, Republic of Korea.
| | - Byung-Soo Park
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, 20 Geumo-Ro, Yangsan-Si, Gyeongsangnam-Do, 50612, Republic of Korea
| | - Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, 20 Geumo-Ro, Yangsan-Si, Gyeongsangnam-Do, 50612, Republic of Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, 20 Geumo-Ro, Yangsan-Si, Gyeongsangnam-Do, 50612, Republic of Korea
| | - Mi Sook Yun
- Division of Biostatistics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Farah A, Malshy K, Tatakis A, Abboud W, Mari A, Sayida S. Nonoperative Management Strategies for Anastomotic Leaks After One Anastomosis Gastric Bypass (OAGB): A Literature Review. Cureus 2024; 16:e69708. [PMID: 39429265 PMCID: PMC11489929 DOI: 10.7759/cureus.69708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2024] [Indexed: 10/22/2024] Open
Abstract
One Anastomosis Gastric Bypass (OAGB) has gained widespread acceptance as an effective bariatric surgery due to its relative simplicity and favorable outcomes in weight loss and metabolic improvement. However, anastomotic leaks, though uncommon, present a significant complication with the potential for severe morbidity and mortality if not managed appropriately. This review examines the range of nonoperative strategies currently employed to manage anastomotic leaks and fistulae following OAGB. The focus is on endoscopic techniques, including the use of clips, stents, suturing systems, internal drainage, vacuum therapy, and tissue sealants, which have been successfully used in various gastrointestinal surgeries. Although a proportion of patients will require surgical treatments, these strategies offer less invasive alternatives to surgical intervention and can be tailored to the specific characteristics of the leak and patient condition. However, the application of these techniques specifically for OAGB-related leaks is not as well-documented. This review lists the available evidence on these nonoperative approaches, highlighting some of their potential benefits and limitations. While these methods show promise, there is a clear need for further research to establish standardized protocols and optimize their use in the context of OAGB-related leaks and fistulae.
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Affiliation(s)
- Amir Farah
- General Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Kamil Malshy
- Urology, University of Rochester Medical Center, Rochester, USA
| | - Anna Tatakis
- General Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Wisam Abboud
- General Surgery, Edinburgh Medical Missionary Society (EMMS) Nazareth Hospital, Nazareth, ISR
| | - Amir Mari
- Gastroenterology and Hepatology, Edinburgh Medical Missionary Society (EMMS) Nazareth Hospital, Nazareth, ISR
| | - Sa'd Sayida
- General Surgery, Edinburgh Medical Missionary Society (EMMS) Nazareth Hospital, Nazareth, ISR
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Kondo A, Yokota N, Kobayashi N, Feng D, Asano E, Kumamoto K, Kobara H, Okano K. A Novel Fluorescence-Based Leak Test Method for Rectal Anastomoses Using Aerosolized Indocyanine Green. Dis Colon Rectum 2024; 67:168-174. [PMID: 37787549 DOI: 10.1097/dcr.0000000000002897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND The intraoperative air leak test is commonly performed during rectal surgery to evaluate anastomotic integrity. However, its drawbacks include occasional difficulties in visualizing the exact point of the leak while maintaining the pelvis under saline, the need for repeat testing to identify the leak point, and a lack of continuous visualization of the leak point. OBJECTIVE To evaluate the feasibility and clinical applicability of using aerosolized indocyanine green, a fluorescent tracer, for detecting rectal anastomotic leakage. DESIGN Animal preclinical study. SETTING Animal laboratory at Kagawa University. PATIENTS Six healthy adult female beagles were included. INTERVENTIONS An anastomotic leakage model with a single air leak point was created in each dog. Indocyanine green was aerosolized using a nebulizer kit with a stream of carbon dioxide flowing at 1.5 to 2.0 L/min. The aerosol was administered into the rectum transanally, and laparoscopic observations were performed. MAIN OUTCOME MEASURES Air leak points were observed using a near-infrared fluorescence laparoscope, after which the presence of corresponding indocyanine green fluorescence was verified. RESULTS Aerosolized indocyanine green was visualized laparoscopically at all anastomosis sites but not elsewhere. The median time from the administration of the aerosol to its visualization was 4.5 seconds. Pathological examinations were performed 4 weeks postsurgery in all dogs, and no histological abnormalities related to aerosolized indocyanine green administration were observed at the anastomosis sites. LIMITATIONS The leak points were surgically created and did not occur naturally. CONCLUSIONS Visualization of air leaks at the sites of rectal anastomosis was laparoscopically achievable by administering aerosolized indocyanine green transanally into the rectum in our canine model. This novel fluorescent leak test could be a valid alternative to established methods.
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Affiliation(s)
- Akihiro Kondo
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Naoya Yokota
- Department of General Thoracic Surgery, Breast, and Endocrinological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Nobuya Kobayashi
- Department of Gastroenterology and Neurology, Kagawa University, Takamatsu, Japan
| | - Dongping Feng
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Eisuke Asano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Kensuke Kumamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Kagawa University, Takamatsu, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
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Wang Q, Li J, Liu S, Fang C, Chen W. Efficacy and safety of over-the-scope clips for colorectal leaks and fistulas: a pooled analysis. MINIM INVASIV THER 2022; 31:825-834. [PMID: 34871538 DOI: 10.1080/13645706.2021.2010218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
The development of laparoscopic technologies and continuous improvements in intracavitary anastomosis technology have significantly reduced the incidence of anastomotic leak (AL) following colorectal surgery. However, AL incidence can significantly increase the duration of patient hospitalization, patient medical expenses, and incidence of mortality. The recently developed over-the-scope clip (OTSC) system has been of increasing clinical interest owing to its ease of use, low complication rates, and high rates of technical and clinical success. The PubMed/Medline, EMBASE, and Cochrane PubMed Library were systematically searched for all studies of OTSC system-mediated closure of ALs and fistulas published from January 2010 to January 2021. Two reviewers independently identified relevant studies based on appropriate inclusion and exclusion criteria. A total of nine studies were included in the present analysis, incorporating 114 patients of whom 107 were treated with an OTSC system. The technical success rate for these patients was 84% (95%CI, 73.5-94.5%; I2 53%), and the clinical success rate was 74.3% (95%CI, 64.4-84.1%; I2 28%) as calculated via a pooled proportion analysis. Complications occurred in two patients. The endoscopic OTSC system is a safe and effective means of treating ALs and fistulas after colorectal surgery.
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Affiliation(s)
- Qianyu Wang
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Jie Li
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Shuang Liu
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Changzhong Fang
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Wenliang Chen
- Department of General Surgery, The 2nd Affiliated Hospital of Shanxi Medical University, Taiyuan, China
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Kishiki T, Kojima K, Aso N, Iioka A, Wakamatsu T, Kataoka I, Kim S, Ishii S, Isobe S, Sakamoto Y, Abe N, Sunami E. Intraoperative Colonoscopy in Laparoscopic Rectal Cancer Surgery Reduces Anastomotic Leakage. J Anus Rectum Colon 2022; 6:159-167. [PMID: 35979268 PMCID: PMC9328792 DOI: 10.23922/jarc.2022-003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/22/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: Anastomotic leakage (AL) is the most severe complication of colorectal surgery and is a frequent cause of postoperative mortality. This study aimed to identify the risk factors for AL, including the type of air leak test (ALT) performed, in patients undergoing laparoscopic colorectal cancer surgery. Methods: This study involved a retrospective review of 201 patients who underwent elective laparoscopic procedures using circular stapled anastomosis for colorectal cancer between January 2015 and December 2020 at Kyorin University Hospital, Tokyo, Japan. In all cases, the distance from the anal verge to the anastomotic site was within 15 cm. Results: Overall, AL was observed in 16 patients (8.0%). Univariate analysis revealed that the risk factors for AL included diabetes (P = 0.068), tumor location (P = 0.049), level of anastomosis (P = 0.002), number of linear stapler firings (P = 0.007), and intraoperative colonoscopy (IOCS; P = 0.069). Multivariate analysis revealed that the level of anastomosis (P = 0.029) and IOCS (P = 0.039) were significant and independent risk factors for AL. One of the 107 patients undergoing ALT without IOCS and 3 of the 94 patients undergoing ALT with IOCS were proven to be positive for air leak. However, these four patients underwent additional suturing intraoperatively and developed no AL following surgery. Conclusions: This study identified the level of anastomosis and ALT with IOCS as predictors for AL. The results of our study indicate that ALT with IOCS may be more effective than ALT without IOCS in the diagnosis and prevention of AL.
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Affiliation(s)
| | | | - Nobuyoshi Aso
- Department of Surgery, Kyorin University School of Medicine
| | - Aiko Iioka
- Department of Surgery, Kyorin University School of Medicine
| | | | - Isao Kataoka
- Department of Surgery, Kyorin University School of Medicine
| | - Sangchul Kim
- Department of Surgery, Kyorin University School of Medicine
| | - Shun Ishii
- Department of Surgery, Kyorin University School of Medicine
| | - Satoshi Isobe
- Department of Surgery, Kyorin University School of Medicine
| | | | - Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine
| | - Eiji Sunami
- Department of Surgery, Kyorin University School of Medicine
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The Risk Factors of Anastomotic Leakage After Rectal Cancer Surgery. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm-120889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Anastomotic leakage is a significant complication after colorectal anastomosis. The aim of this study was to evaluate the risk factors and preventive measures for anastomotic leakage after rectal cancer surgery. Methods: A total of 171 patients who had undergone laparoscopic and open rectal cancer resection with a double stapling participated in this study. Twelve independent variables include age, sex, obesity, smoking, ASA grading, medical diseases, preoperative radiotherapy, preoperative chemotherapy, splenic flexure mobilization, diverting ileostomy, and the number of stapler firing were analyzed. Results: The anastomotic leakage rate was 2.33% (4 of 171). The mean age of the patients was 58.33 years old while their mean body mass index (BMI) was calculated as 24.10 kg/m2. In our study, 16.3% of patients were cigarette smokers. Of the 171 rectal surgeries, 69.0% of patients were diverted by loop ileostomy and 1.16% were supported by ghost ileostomy. Of 171 patients included in this study, 17.5 % of patients required a single staple firing for rectal division. In contrast, 47.9% of patients required 2 linear staplers, others, 24.5% of patients required 3 cartridges for rectal division, and 9.9% of patients required 4 cartridges in their surgeries. There were significant differences between men and women in the number of cartridges used (P = 0.023). Conclusions: All our leakage cases were men and the higher number of stapler firings for rectal division, history of smoking; male gender, and level of anastomosis were independent risk factors for the anastomotic leak.
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Valdes-Hernandez J, Cintas-Catena J, Del Rio-Lafuente FJ, Cano-Matias A, Torres-Arcos C, Perez-Sanchez A, Capitan-Morales L, Oliva-Mompean F, Gomez-Rosado JC. Initial experience with intraoperative testing and repair of colorectal anastomosis using a TAMIS approach after a positive leak test. Tech Coloproctol 2022; 26:901-904. [PMID: 35727427 DOI: 10.1007/s10151-022-02635-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/30/2022] [Indexed: 11/29/2022]
Abstract
Anastomotic leak is one of the most feared complications of colorectal anastomosis. Different techniques have been described for intraoperative testing of anastomotic integrity. These include air insufflation, methylene blue and endoscopic visualisation. If an anastomotic leak is identified intraoperatively, there are various management options. Redo anastomosis is a possibility, but may be difficult in some cases. Defunctioning is another option, but there is an associated morbidity and signficant detrimental effect on quality of life. Direct transanal repair is only possible when a low anastomosis has been performed. When the anastomotic leak occurs high in the rectum or a partial mesorectal excision is performed a transanal approach is technically very challenging. We present our experience with transanal minimally invasive surgery (TAMIS) approach for anastomotic assessment and repair in four patients. In all cases, a colorectal anastomosis was performed and the air insufflation test was positive. We assessed the anastomosis with TAMIS. In three cases, a defect was found and subsequently sutured. In one case, a scar in the rectal mucosa was found and reinforced with a suture. A protective ileostomy was performed in two cases, while in the other two cases, no stoma was added. All four patients were discharged with no further complications. Both protective ileostomies were taken down after radiological and endoscopic confirmation of anastomotic integrity and all 4 anastomoses remain intact after follow-up. TAMIS intraoperative assessment and repair of anastomotic leak is a safe and feasible technique whcih may avoid the need for a defunctioning stoma.
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Affiliation(s)
- J Valdes-Hernandez
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain.
| | - J Cintas-Catena
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - F J Del Rio-Lafuente
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - A Cano-Matias
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - C Torres-Arcos
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - A Perez-Sanchez
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - L Capitan-Morales
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - F Oliva-Mompean
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
| | - J C Gomez-Rosado
- Colorectal Surgery Unit, General and Digestive Surgery Unit, Virgen Macarena University Hospital, Dr Fedriani s/n 41003, Seville, Spain
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Kryzauskas M, Bausys A, Dulskas A, Imbrasaite U, Danys D, Jotautas V, Stratilatovas E, Strupas K, Poskus E, Poskus T. Comprehensive testing of colorectal anastomosis: results of prospective observational cohort study. Surg Endosc 2022; 36:6194-6204. [PMID: 35146557 DOI: 10.1007/s00464-022-09093-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anastomotic leakage remains one of the most threatening complications in colorectal surgery. Intraoperative testing of anastomosis may reduce the postoperative anastomotic leakage rates. This study aimed to investigate a novel comprehensive intraoperative colorectal anastomosis testing technique to detect the failure of the anastomosis construction and to reduce the risk of postoperative leak. METHODS This multi-centre prospective cohort pilot study included 60 patients who underwent colorectal resection with an anastomosis at or below 15 cm from the anal verge. Comprehensive trimodal testing consisted of indocyanine green fluorescence angiography, tension testing, air-leak, and methylene blue leak tests to evaluate the perfusion, tension, and mechanical integrity of the anastomosis. RESULTS Ten (16.7%) patients developed an anastomotic leakage. Trimodal test was positive in 16 (26.6%) patients and the operative plan was changed for all of them. Diverting ileostomy was performed in 14 (87.5%) patients. However, two (12.5%) patients still developed clinically significant anastomotic leakage (Grade B). Forty-four (73.4%) patients had a negative trimodal test, preventive ileostomy was performed in 19 (43.2%), and five (11.4%) patients had clinically significant anastomotic leakage (Grade B and C). CONCLUSION Trimodal testing identifies anastomoses with initial technical failure where reinforcement of anastomosis or diversion can lead to an acceptable rate of anastomotic leakage. Identification of well-performed anastomosis could allow a reduction of ileostomy rate by two-fold. However, anastomotic leakage rate remains high in technically well-performed anastomoses.
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Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Ciurlionio Str., 03101, Vilnius, Lithuania.
| | - Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Ciurlionio Str., 03101, Vilnius, Lithuania
| | | | | | - Donatas Danys
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Valdemaras Jotautas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Ciurlionio Str., 03101, Vilnius, Lithuania
| | | | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Ciurlionio Str., 03101, Vilnius, Lithuania
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Ciurlionio Str., 03101, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Ciurlionio Str., 03101, Vilnius, Lithuania
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Castaño R, Molina-Meneses SP, Puerta JD, Palacios LJ, Jaramillo R, Piñeres A, Aristizábal F. Impact of intraoperative colonoscopy on anastomotic leakage detection and prevention in colorectal anastomosis for rectal cancer. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 87:312-319. [PMID: 34872887 DOI: 10.1016/j.rgmxen.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/03/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND AIM The value of leakage testing during colorectal resections to identify anastomotic leaks or bleeding has not been established. Our aim was to compare the impact of intraoperative colonoscopy (IOC) versus insufflation with a syringe, as leakage testing in lower anterior resection (LAR) for rectal cancer, with respect to the incidence of postoperative leakage (PL). MATERIALS AND METHODS A retrospective study utilizing a prospective database of 426 patients with rectal cancer that underwent elective LAR, within the time frame of January 2015 and December 2019, was conducted. The anastomotic leak test was chosen by the surgeon. The incidence of postoperative leakage was compared between patients that underwent IOC and those that had the syringe leak test, utilizing the logistic regression analysis. Propensity score matching was included. RESULTS There were no significant differences in the clinical characteristics or morbidity and mortality rates between the two groups. Four patients were excluded, leaving a patient total of 422. Seventy patients with IOC were compared with 352 that had the syringe leak test. The incidence of postoperative leakage was 5.7% in the IOC group and 12.2% in the control group (p = 0.001). After propensity score matching (n = 221), balancing the characteristics between the groups, the incidence of postoperative leakage was 5.7% in the IOC group and 13.9% in the syringe leak test group (p = 0.001). CONCLUSION IOC was shown to be a safe method for evaluating the integrity of colorectal anastomosis and was associated with a higher percentage of protective stoma use, appearing to reduce the risk for PL.
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Affiliation(s)
- R Castaño
- Cirugía Gastrointestinal y Endoscopia, Grupo de Gastrohepatología, Universidad de Antioquia, Instituto de Cancerología, Clínica Las Américas, AUNA, Medellín, Antioquia, Colombia
| | - S P Molina-Meneses
- Cirugía General, Instituto de Cancerología, Clínica Las Américas, AUNA, Medellín, Antioquia, Colombia.
| | - J D Puerta
- Coloproctología, Clínica Las Américas, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia
| | - L J Palacios
- Cirugía Oncológica, Instituto de Cancerología, Clínica Las Américas, AUNA, Medellín, Antioquia, Colombia
| | - R Jaramillo
- Cirugía Oncológica, Instituto de Cancerología, Clínica Las Américas, AUNA, Medellín, Antioquia, Colombia
| | - A Piñeres
- Cirugía Gastrointestinal y Endoscopia, Instituto de Cancerología, Clínica Las Américas, AUNA, Medellín, Antioquia, Colombia
| | - F Aristizábal
- Cirugía General, Instituto de Cancerología, Clínica Las Américas, AUNA, Medellín, Antioquia, Colombia
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Culbertson TF, Smeak DD, Rao S. Volume of saline (0.9% NaCl) solution required to reach maximum peristaltic pressure in cadaveric intact jejunal specimens from dogs of various sizes. Am J Vet Res 2021; 82:988-995. [PMID: 34714768 DOI: 10.2460/ajvr.21.05.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the volume of saline (0.9% NaCl) solution required to reach a maximum intraluminal peristaltic pressure of 25 mm Hg in dogs of various sizes. SAMPLES 25 grossly normal jejunal segments from 6 canine cadavers < 20 kg (small dogs) and 25 segments from 5 cadavers ≥ 20 kg (large dogs). PROCEDURES Jejunal specimens were obtained within 1.5 hours after euthanasia. Harvested tissue was transected into 12-cm-long segments, mesentery was trimmed, and each segment was measured from the antimesenteric to mesenteric serosal edges. A 10-cm segment was isolated with Doyen forceps, securing a pressure sleeve within the lumen. Intraluminal saline was infused, and the volume was recorded when a pressure of > 25 mm Hg was achieved. Data were analyzed only from specimens in which the pressure remained between 24 and 26 mm Hg for > 5 seconds. RESULTS Mean ± SD intestinal measurement for large dogs (17.82 ± 1.44 mm) was greater than that for small dogs (12.38 ± 1.38 mm) as was the volume of saline solution infused (17.56 ± 7.17 mL vs 3.28 ± 1.41 mL, respectively). The volume infused increased by 1.31 mL (95% CI, 1.08 to 1.18) for every 1-mm increase in intestinal measurement and by 1.06 mL (95% CI, 1.052 to 1.068) for every 1-kg increase in body weight. CONCLUSIONS AND CLINICAL RELEVANCE The volume of saline solution used for intestinal leak testing should be determined on the basis of patient intestinal measurement or body weight. In vivo studies are necessary to establish the optimal volume for intestinal leak testing.
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Affiliation(s)
- Tricia F Culbertson
- From the Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523
| | - Daniel D Smeak
- From the Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523
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Mullen KM, Regier PJ, Waln M, Colee J. Ex vivo comparison of leak testing of canine jejunal enterotomies: Saline infusion versus air insufflation. Vet Surg 2021; 50:1257-1266. [PMID: 33983659 DOI: 10.1111/vsu.13652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/31/2021] [Accepted: 04/20/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To compare the ability to detect leakage of enterotomy closures by intraluminal injection of saline or air. STUDY DESIGN Ex vivo study. ANIMALS Grossly normal jejunal segments (n = 60) from five fresh canine cadavers. METHODS Eight-centimeter jejunal segments were randomly assigned to two control (saline control [n = 5], air control [5]) and two treatment groups (injection of saline [n = 25] or air [25] after enterotomies were closed in a simple continuous pattern using 4-0 glycomer 631). Initial leak pressure (ILP, mean ± SD), maximum intraluminal pressure (MIP), and leakage location were compared. For all air insufflation constructs, the volume of air insufflated at the time of initial leakage was recorded. RESULTS The ILPs of control segments did not differ whether injected with saline (405.71 ± 56.97 mmHg) or air (376.84 ± 42.54, p = 1.00). Enterotomy closures leaked at lower pressures when injected with air (ILP: 68.52 ± 6.56) compared to saline (87.76 ± 5.20, p = .03). Similar results were obtained when comparing MIPs. A moderate association (r = .51) was identified between volume of air infused and ILPs. The strength of the association improved when stratified by cadaver. The location of leakage-most commonly suture tracks-was identified for all air constructs and for 14 of 25 saline constructs. CONCLUSION Enterotomy closures leaked at lower pressures after intraluminal injection of air compared to saline. CLINICAL SIGNIFICANCE Intraoperative leak testing of small intestinal enterotomy closures may be rendered more sensitive and precise by the use of air instead of saline as the infusate.
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Affiliation(s)
- Kaitlyn M Mullen
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Penny J Regier
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Monica Waln
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - James Colee
- Department of Statistics, College of Liberal Arts and Sciences University of Florida, Gainesville, Florida, USA
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12
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Intraoperative evaluation of colorectal anastomotic integrity: a comparison of air leak and dye leak tests. Tech Coloproctol 2021; 25:841-847. [PMID: 33905010 DOI: 10.1007/s10151-021-02453-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Air leak tests (ALTs) and dye leak tests (DLTs) are the most common techniques for Intraoperative colorectal anastomosis assessment. The aim of our study was to compare the sensitivity of ALT with DLT in intraoperative evaluation of colorectal anastomotic integrity and to quantify the pressures routinely used in these tests. METHODS A prospective clinical trial was conducted on patients who had elective colorectal resection and primary anastomosis from November 2017 until July 2019 in a single academic referral center. Each patient underwent both tests. The ALT was a transanal insufflation of CO2 and inspection of escaping bubbles around the anastomosis immersed in saline. The DLT was a transanal infusion of diluted methylene blue and inspection of dye stains on surgical gauze wrapping the anastomosis. Peak pressures were measured. Primary endpoints were the sensitivity of ALT and DLT in detecting intraoperative leaks, quantification of intraluminal pressure routinely used in these settings and assessment of postoperative complications such as a clinical leak. RESULTS Forty patients underwent elective colorectal resection and anastomosis for malignant (67%) or benign n (33%) etiology. Height of anastomoses ranged from 1 to 25 cm (mean ± SD 12 ± 6 cm). Mean pressures measured were 26.5 ± 6.6 mmHg for the DLT and 22 ± 4 mmHg for the ALT (p < 0.01). Twenty percent of the DLTs were positive (8 patients) compared to 2.5% (1 patient) of the ALTs (RR 1.97, CI 1.2-2.7; p = 0.03). All patients who had positive tests had a suture reinforcement of the anastomosis. Only 1 patient, who had a positive DLT and ALT, developed a clinical leak CONCLUSIONS: DLT is more sensitive in detecting anastomotic leak intraoperatively. This is the first study measuring anastomotic tests' pressures used in-vivo in humans demonstrating a range of 20-30 mmHg. Based on our data we believe that a positive DLT with a negative ALT may be treated with suture reinforcement alone. CLINICAL TRIAL NUMBER NCT03316677-10/17/2017.
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13
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Tschann P, Girotti P, Lechner D, Feurstein B, Adler S, Hufschmidt M, Königsrainer I. Does intraoperative flexible endoscopy offer any benefit compared to conventional air leak testing after circular stapled left-sided laparoscopic colon surgery? Minerva Surg 2021; 76:586-591. [PMID: 33890443 DOI: 10.23736/s2724-5691.21.08705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Anastomotic leakage is still a feared complication after left-sided colonic resections. Various types of "anastomotic leak testing methods" are described in current literature. In this study we evaluated the use of intraoperative flexible endoscopy in comparison to conventional air leak testing after performing a circular stapled anastomosis in left-sided laparoscopic colon surgery. METHODS A retrospective database consisting of 130 patients with left sided colonic resections between 01/2015 and 12/2019 at our hospital was evaluated. After performing a circular stapled anastomosis flexible endoscopy was done in 69 cases, 61 patients were controlled with a conventional air leak test. Intraoperative and postoperative complications were recorded and retrospectively evaluated. RESULTS In the flexible endoscopy group, we observed complications in 13,04%, in the conventional air leak testing group in 9,83%. Postoperative anastomotic leakage was observed in 10,14% in the flexible endoscopy group and 4,91% in the conventional air leak test group. In 10,14% a positive air leak test was seen in the flexible endoscopy group and 11,47% in the conventional air leak testing group. In those cases, we observed no postoperative complications in the first group, in the conventional group we had two anastomotic leakages and one infected haematoma. CONCLUSIONS In the case of a positive air leak, flexible endoscopy offered a more exact detection of the leak. In those cases, no anastomotic leakage was observed postoperatively. In our opinion, flexible endoscopy should be recommended for testing the anastomosis intraoperatively in every left-sided colon surgery.
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Affiliation(s)
- Peter Tschann
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria -
| | - Paolo Girotti
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Daniel Lechner
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Benedikt Feurstein
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Stephanie Adler
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Martin Hufschmidt
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Ingmar Königsrainer
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
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14
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Clifford RE, Fowler H, Manu N, Sutton P, Vimalachandran D. Intra-operative assessment of left-sided colorectal anastomotic integrity: a systematic review of available techniques. Colorectal Dis 2021; 23:582-591. [PMID: 32978892 DOI: 10.1111/codi.15380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/26/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
AIM Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer-related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought. METHOD A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990-2020. Additional papers were detected by scanning references of relevant papers. RESULTS A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air-leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra-operatively provides the opportunity for either suture reinforcement or formal takedown with or without re-do of the anastomosis and consideration of diversion. Suture repair alone of a positive air-leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future. CONCLUSION Although over reliance on any assessment tool should be avoided, intra-operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra-operatively for mechanical failure, particularly distal anastomoses.
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Affiliation(s)
| | - Hayley Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Nicola Manu
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Paul Sutton
- Institute of Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Dale Vimalachandran
- Institute of Cancer Medicine, University of Liverpool, Liverpool, UK.,Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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15
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Better Safe than Sorry: Prevention of Esophagojejunostomy Leak by Intraoperative Methylene Blue Test in Advanced Gastric Cancer. J Gastrointest Surg 2021; 25:2401-2403. [PMID: 33559098 PMCID: PMC8484250 DOI: 10.1007/s11605-021-04921-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/12/2021] [Indexed: 01/31/2023]
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16
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Kryzauskas M, Bausys A, Jakubauskas M, Valciukiene J, Makunaite G, Jasiunas E, Bausys R, Poskus E, Strupas K, Poskus T. Intraoperative testing of colorectal anastomosis and the incidence of anastomotic leak: A meta-analysis. Medicine (Baltimore) 2020; 99:e23135. [PMID: 33217816 PMCID: PMC7676546 DOI: 10.1097/md.0000000000023135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 08/15/2020] [Accepted: 10/15/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AL remains one of the most threatening complications in colorectal surgery. Significant efforts are put to understand the pathophysiological mechanisms involved in the development of leakage and to create the strategies to prevent it. We aimed to determine whether intraoperative testing of mechanical integrity and perfusion of colorectal anastomosis could reduce the incidence of AL. METHODS A systematic review and meta-analysis of papers published before November 2019 on PubMed, Scopus, Web of Science, and Cochrane Library databases and comparing intraoperative testing of the colorectal anastomosis with standard care were conducted. Odds ratios (ORs) and 95% confidence interval (CIs) were used to assess the association between intraoperative testing and AL. RESULTS A total of 23 studies totaling 7115 patients were included. Pooled analysis revealed intraoperative tests, for integrity (OR 0.52, 95% CI 0.34-0.82, P < .001) and perfusion (OR 0.40, 95% CI 0.22-0.752, P < .001) of the lower gastrointestinal tract anastomoses are associated with significantly lower AL rate. CONCLUSIONS Intraoperative testing for either integrity or perfusion of anastomoses both reduce the AL rate. Studies looking at the combination of these two testing methods of anastomosis, especially intraoperative endoscopy, and indocyanine green fluorescence angiography may be very promising to further reduction of the AL.
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Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Matas Jakubauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Jurate Valciukiene
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Gabija Makunaite
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Eugenijus Jasiunas
- Center of Informatics and Development, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Rimantas Bausys
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University
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17
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Kryzauskas M, Degutyte AE, Abeciunas V, Lukenaite B, Jasiunas E, Poskus E, Strupas K, Poskus T. Experimental Study of Mechanical Integrity Testing in Stapled Large Bowel: Methylene Blue Leak Test Is Not Inferior to Air Leak Test. Visc Med 2020; 37:189-197. [PMID: 34250076 DOI: 10.1159/000510660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022] Open
Abstract
Background/Objectives Anastomotic leakage remains the most devastating postoperative complication in colorectal surgery. The mechanical integrity of the newly formed colorectal anastomosis can be evaluated by visual inspection intraoperatively; both air leak and liquid leak tests are also used to evaluate the integrity of stapled colorectal anastomoses. It is not clear whether double-stapled anastomoses are more prone to leaks than single-stapled anastomoses. The aim of our study was to compare the methylene blue and the air leak test in the experimental setting of single-stapled and double-stapled porcine bowels. Methods Twenty-four distal colons were excised from slaughtered pigs without delay. The proximal bowel end was closed with a linear stapler using blue cartridges. The bowels were randomly divided into single-stapled or double-stapled groups. Air leak and methylene blue leak tests were performed. A digital pressure monitor with a gradual pressure increase function was used to both gradually increase pressure within the bowel and to determine the pressure at which the stapler line disintegrated. Results Air leakage occurred at a mean pressure of 51.62 (±16.60) mm Hg and methylene blue leakage occurred at 46.54 (±16.78) mm Hg (p = 0.31). The air and methylene blue leaks occurred at comparable pressures in single-stapled bowels and in double-stapled bowels (47.21 [±14.02] mm Hg vs. 50.96 [±19.15] mm Hg, p = 0.6). Conclusions The methylene blue solution leak test is not inferior to the air leak test. There is no significant difference in bursting pressure between single-stapled and double-stapled anastomoses.
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Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | | | - Eugenijus Jasiunas
- Center of Informatics and Development, Vilnius University Hospital "Santaros Klinikos", Vilnius, Lithuania
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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18
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Kryzauskas M, Poskus E, Dulskas A, Bausys A, Jakubauskas M, Imbrasaite U, Makunaite G, Kuliavas J, Bausys R, Stratilatovas E, Strupas K, Poskus T. The problem of colorectal anastomosis safety. Medicine (Baltimore) 2020; 99:e18560. [PMID: 31914032 PMCID: PMC6959889 DOI: 10.1097/md.0000000000018560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Anastomotic leakage (AL) remains one of the most threatening complications in colorectal surgery with the incidence of up to 20%. The aim of the study is to evaluate the safety and feasibility of novel - trimodal intraoperative colorectal anastomosis testing technique. METHODS AND ANALYSIS This multi-center prospective cohort pilot study will include patients undergoing colorectal anastomosis formation below 15 cm from the anal verge. Trimodal anastomosis testing will include testing for blood supply by ICG fluorescence trans-abdominally and trans-anally, testing of mechanical integrity of anastomosis by air-leak and methylene blue leak tests and testing for tension. The primary outcome of the study will be AL rate at day 60. The secondary outcomes will include: the frequency of changed location of bowel resection; ileostomy rate; the rate of intraoperative AL; time, taken to perform trimodal anastomosis testing; postoperative morbidity and mortality; quality of life. DISCUSSION Trimodal testing of colorectal anastomosis may be a novel and comprehensive way to investigate colorectal anastomosis and to reveal insufficient blood supply and integrity defects intraoperatively. Thus, prevention of these two most common causes of AL may lead to decreased rate of leakage. STUDY REGISTRATION Clinicaltrials.gov (https://clinicaltrials.gov/): NCT03958500, May, 2019.
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19
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Aly M, O'Brien JW, Clark F, Kapur S, Stearns AT, Shaikh I. Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis. Colorectal Dis 2019; 21:1354-1363. [PMID: 31243879 DOI: 10.1111/codi.14740] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
AIM Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity. METHODS PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates. RESULTS Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB. CONCLUSION This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.
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Affiliation(s)
- M Aly
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - J W O'Brien
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - F Clark
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - S Kapur
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - A T Stearns
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - I Shaikh
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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20
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Sinovich M, Archer DC, Meunier NV, Kelly PG. Ex vivo comparison of barbed sutures for pelvic flexure enterotomy in horses. Vet Surg 2019; 49:487-495. [PMID: 31724764 DOI: 10.1111/vsu.13353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/13/2019] [Accepted: 09/21/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate two different barbed sutures for closure of pelvic flexure enterotomies and compare results achieved with two previously described closure techniques. STUDY DESIGN Ex vivo. SAMPLE POPULATION Twenty-four fresh cadaver adult equine large colons. METHODS Cadavers were randomly assigned to four closure groups (n = 6 each group): single-layer absorbable suture, double-layer absorbable suture, single-layer unidirectional barbed suture, or single-layer bidirectional barbed suture. Construction time, luminal reduction (percentage), bursting pressure, and method of failure were measured. Cost, leakage, exposed suture, and general appearance were recorded. Comparisons were performed with one-way analysis of variance and post hoc Bonferroni test (P < .05). RESULTS Double-layer absorbable closure had the highest bursting pressure (mean = 178.5 mm Hg, SD = 9.79, P < .001) but took more time (P = .001) compared with all other groups. The construction time of both barbed suture closures did not differ from the single-layer closure (P > .06). Bursting strengths of both unidirectional (mean = 91.6 mm Hg, SD = 5.57) and bidirectional (mean = 87.5 mm Hg, SD = 8.69) barbed sutures were lower (P > .006 for both) than those of both single- (mean = 117.6 mm Hg, SD = 11.69) and double-layer (mean = 178.5 mm Hg, SD = 9.79) closures. Unidirectional barbed suture closure had a reduction in lumen diameter (P = .004) compared with bidirectional and single-layer closures. CONCLUSION Enterotomy closures with the two different barbed suture patterns were comparable in bursting strength and construction time. However, the barbed suture patterns had lower bursting strength compared with traditional single- and double-layer closures. Unidirectional barbed suture closure also reduced lumen diameter. CLINICAL SIGNIFICANCE Closure of a large colon enterotomy with barbed suture patterns may be less secure than single- and double-layer suture closure.
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Affiliation(s)
- Matthew Sinovich
- The Philip Leverhulme Equine Hospital, University of Liverpool, Neston, United Kingdom
| | - Debbie C Archer
- The Philip Leverhulme Equine Hospital, University of Liverpool, Neston, United Kingdom
| | - Natascha V Meunier
- The Epidemiology, Economics and Risk Assessment Group, The Roslin Institute, Royal (Dick) School of Veterinary Studies, Easter Bush, United Kingdom
| | - Padraig G Kelly
- The Philip Leverhulme Equine Hospital, University of Liverpool, Neston, United Kingdom
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21
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Ghoz H, Brahmbhatt B, Odah T, Foulks C, Woodward TA. Endoscopic identification and clipping of an anastomotic leak after colorectal surgery by use of methylene blue dye and over-the-scope clipping system. VideoGIE 2019; 4:476-477. [PMID: 31709335 PMCID: PMC6831911 DOI: 10.1016/j.vgie.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Tarek Odah
- Division of General Internal Medicine, MetroWest Medical Center, Framingham, Massachusetts, USA
| | - Carla Foulks
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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22
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Poskus T, Luksta M, Kryzauskas M. Technique of air-leak testing of ileocolic anastomosis. Tech Coloproctol 2018; 22:813-815. [PMID: 30456643 DOI: 10.1007/s10151-018-1882-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Affiliation(s)
- T Poskus
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania. .,Vilnius University Hospital Santara Clinics, Santariskiu 2, 08661, Vilnius, Lithuania.
| | - M Luksta
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - M Kryzauskas
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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23
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Celik S, Almalı N, Aras A, Yılmaz Ö, Kızıltan R. Intraoperatively Testing the Anastomotic Integrity of Esophagojejunostomy Using Methylene Blue. Scand J Surg 2016; 106:62-67. [DOI: 10.1177/1457496916630652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Intraoperative testing of gastrointestinal anastomosis effectively ensures anastomotic integrity. This study investigated whether the routine use of methylene blue intraoperatively identified leaks to reduce the postoperative proportion of clinical leaks. Methods: This study retrospectively analyzed consecutive total gastrectomies performed from January 2007 to December 2014 in a university hospital setting by a general surgical group that exclusively used the methylene blue test. All surgeries were performed for gastric or junctional cancers (n = 198). All reconstructions (Roux-en Y esophagojejunostomy) were performed using a stapler. The methylene blue test was used in 108 cases (group 1) via a nasojejunal tube. No test was performed for the other 90 cases (group 2). Intraoperative leakage rate, postoperative clinical leakage rate, length of hospitalization, and mortality rate were the outcome measures. Results: The intraoperative leakage rate was 7.4% in group 1. The postoperative clinical leakage rate was 8.6%. The postoperative clinical leakage rate was 3.7% in group 1 and 14.4% in group 2 (p = 0.007). There were no postoperative clinical leaks when an intraoperative leak led to concomitant intraoperative repair. The median length of hospital stay was 6 days in group 1 and 8 days in group 2 (p < 0.001). One death occurred in each group. No test-related complications were observed. Conclusion: The methylene blue test for esophagojejunostomy is a safe and reliable method for the assessment of anastomosis integrity, especially in cases with difficult esophagojejunostomic construction.
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Affiliation(s)
- S. Celik
- Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - N. Almalı
- General Surgery Clinic, Van Training and Research Hospital, Van, Turkey
| | - A. Aras
- Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - Ö. Yılmaz
- Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - R. Kızıltan
- Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
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Bingham J, Lallemand M, Barron M, Kuckelman J, Carter P, Blair K, Martin M. Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air? Am J Surg 2016; 211:943-7. [PMID: 27020902 DOI: 10.1016/j.amjsurg.2016.02.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak. METHODS Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed. RESULTS Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6). CONCLUSIONS The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.
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Affiliation(s)
- Jason Bingham
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA.
| | - Michael Lallemand
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Morgan Barron
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - John Kuckelman
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Preston Carter
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Kelly Blair
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
| | - Matthew Martin
- Department of General Surgery, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431, USA
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Kamal T, Pai A, Velchuru VR, Zawadzki M, Park JJ, Marecik SJ, Abcarian H, Prasad LM. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Colorectal Dis 2015; 17:160-4. [PMID: 25359528 DOI: 10.1111/codi.12809] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 08/15/2014] [Indexed: 02/06/2023]
Abstract
AIM The aim of the study was to evaluate the value of routine intra-operative flexible sigmoidoscopy (IOFS) for left-sided anastomotic integrity and to determine the safest step after a positive leak test. METHOD All consecutive patients undergoing left-sided colorectal resections for benign and malignant disease between August 2005 and April 2011 were included. Data regarding procedure, type of anastomosis and outcomes of IOFS were collected. A positive intra-operative leak test resulted in redoing the anastomosis and repeating the leak test. RESULTS A total of 415 consecutive patients underwent hand-assisted laparoscopic colorectal resection with a colorectal/ileoanal anastomosis. All patients underwent IOFS. Seventeen patients had abnormality on IOFS. Fifteen patients had a positive air leak test. One patient had anastomotic bleeding. There was one stapler misfiring. Fourteen anastomoses were redone without diversion. One patient required diversion to protect the ileoanal anastomosis and another had already been diverted. Minor bleeding from the staple line in one patient resolved without intervention; however, he had a postoperative anastomotic leak needing surgical intervention. None of the patients who had a takedown and refashioning of the anastomosis following a positive leak on IOFS had postoperative anastomotic leakage or bleeding. Our overall anastomotic leak rate was 2.1%. CONCLUSIONS Intra-operative flexible sigmoidoscopy for restorative colorectal resection is safe and reliable and should be performed routinely to assess anastomotic integrity and bleeding. Refashioning the anastomosis after formal takedown would obviate the risk of leakage and is our recommended method of managing intra-operative leaks.
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Affiliation(s)
- T Kamal
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - A Pai
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - V R Velchuru
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - M Zawadzki
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - J J Park
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - S J Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - H Abcarian
- Department of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - L M Prasad
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA.,Department of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
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Intraoperative assessment of colorectal anastomotic integrity: a systematic review. Surg Endosc 2014; 28:2513-30. [PMID: 24718665 DOI: 10.1007/s00464-014-3520-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons have attempted to minimize postoperative anastomotic complications by employing intraoperative tests and manoeuvres to assess colorectal anastomotic integrity. These have evolved over time with improvement in operative technology and techniques. This systematic review aims to examine the impact of such intraoperative assessments. METHODS A systematic review of studies assessing intraoperative anastomotic assessments and their impact on postoperative anastomotic complications was performed. Intraoperative measures undertaken as a result of intraoperative assessments and postoperative anastomotic complications were analysed. RESULTS 37 Studies were identified. 13 studies evaluated basic mechanical patency tests, ten studies evaluated endoscopic visualisation techniques and 14 studies evaluated microperfusion techniques. Postoperative anastomotic complications were significantly lower in patients tested with basic mechanical patency tests compared to those untested (non-RCT: 4.1 vs. 8.1 %, p = 0.03, RCTs: 5.8 vs. 16.0 %, p = 0.024). There were no differences in postoperative anastomotic complications between tested and non-tested cohorts in non-randomised cohort studies evaluating endoscopic visualisation techniques. However, intraoperative measures taken after abnormal intraoperative tests may have reduced the number of postoperative complications. Perfusion analysis techniques are not in routine widespread clinical practice as yet, but newer techniques such as fluorescent dyes and imaging under near infrared light show technical feasibility. CONCLUSIONS Intraoperative colorectal anastomotic assessment has evolved together with advancement of technology in the surgical setting. Moderate benefit in terms of lower postoperative anastomotic complications has been shown with basic mechanical patency testing and more recently with intraoperative endoscopic visualisation of colorectal anastomoses. The next advance and possible introduction into routine practice may include the use of microperfusion techniques. The latest in this group of techniques, which utilise autofluorescent dyes such as Indocyanine green, hold great potential. Well-planned controlled studies or ideally, randomised controlled trials need to be conducted to further assess the benefit of these latest techniques.
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Daams F, Wu Z, Lahaye MJ, Jeekel J, Lange JF. Prediction and diagnosis of colorectal anastomotic leakage: A systematic review of literature. World J Gastrointest Surg 2014; 6:14-26. [PMID: 24600507 PMCID: PMC3942535 DOI: 10.4240/wjgs.v6.i2.14] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/30/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
Although many studies have focused on the preoperative risk factors of anastomotic leakage after colorectal surgery (CAL), postoperative delay in diagnosis is common and harmful. This review provides a systematic overview of all available literature on diagnostic tools used for CAL. A systematic search of literature was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. Articles were selected when a diagnostic or prediction tool for CAL was described and tested. Two reviewers separately assessed the eligibility and level of evidence of the papers. Sixty-nine articles were selected (clinical methods: 11, laboratory tests: 12, drain fluid analysis: 12, intraoperative techniques: 22, radiology: 16). Clinical scoring leads to early awareness of probability of CAL and reduces delay of diagnosis. C-reactive protein measurement at postoperative day 3-4 is helpful. CAL patients are characterized by elevated cytokine levels in drain fluid in the very early postoperative phase in CAL patients. Intraoperative testing using the air leak test allows intraoperative repair of the anastomosis. Routine contrast enema is not recommended. If CAL is clinically suspected, rectal contrast-computer tomography is recommended by a few studies. In many studies a “no-test” control group was lacking, furthermore no golden standard for CAL is available. These two factors contributed to a relatively low level of evidence in the majority of the papers. This paper provides a systematic overview of literature on the available tools for diagnosing CAL. The study shows that colorectal surgery patients could benefit from some diagnostic interventions that can easily be performed in daily postoperative care.
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Matz BM, Boothe HW, Wright JC, Boothe DM. Effect of enteric biopsy closure orientation on enteric circumference and volume of saline needed for leak testing. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2014; 55:1255-1257. [PMID: 24381348 PMCID: PMC3866861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This study describes the effect of enteric biopsy closure orientation on circumference and volume of saline needed for leak testing. There were significant differences in circumference measurements at baseline, central circumference of longitudinally closed sites, and volume of saline for leak testing.
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Affiliation(s)
- Brad M. Matz
- Address all correspondence to Dr. Brad Matz; e-mail:
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Gandini M, Iotti BN, Giusto G. Biomechanical comparison of four technique for pelvic flexure enterotomy closure in horses. Vet Surg 2013; 42:892-7. [DOI: 10.1111/j.1532-950x.2013.12065.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 07/04/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Marco Gandini
- Department of Veterinary Sciences; University of Turin; Grugliasco; Italy
| | - Bryan N. Iotti
- Department of Veterinary Sciences; University of Turin; Grugliasco; Italy
| | - Gessica Giusto
- Department of Veterinary Sciences; University of Turin; Grugliasco; Italy
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Intraoperative anastomotic dye test significantly decreases incidence of anastomotic leaks in patients undergoing resection for rectal cancer. Tech Coloproctol 2012; 17:579-83. [PMID: 23104550 DOI: 10.1007/s10151-012-0910-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 09/21/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Anastomotic leakage is still a major complication in colorectal surgery. Prompt recognition and immediate treatment of anastomotic leak during surgery may reduce postoperative morbidity and mortality. Various types of intraoperative anastomotic test have been proposed to reduce the incidence of this complication. The aim of this study was to assess our experience with intraoperative dye test in rectal cancer surgery. METHODS Between 2006 and 2009, a retrospective review of a single general surgeon's practice identified 76 patients who underwent the intraoperative dye test in rectal cancer surgery. Seventy-three of these 76 patients underwent elective surgery without creation of a diverting stoma. Diluted dye was routinely introduced into the rectal lumen to test anastomotic integrity. Intraoperative leak was repaired prior to the completion of the procedure. No routine radiological survey assessed anastomotic integrity postoperatively. RESULTS In 11 (14.5 %) out of 76 patients, anastomotic leaks were found and treated intraoperatively. None of the 65 patients without intraoperative leaks developed clinical leaks during the follow-up period. Postoperative leakage only occurred in one patient (1.3 %). He developed pelvic abscess evidenced by abdominal computed tomography scan and was treated non-operatively. CONCLUSIONS The favorable results allow the authors to recommend the routine use of the intraoperative dye test for colorectal anastomoses.
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Kwon S, Morris A, Billingham R, Frankhouse J, Horvath K, Johnson M, McNevin S, Simons A, Symons R, Steele S, Thirlby R, Whiteford M, Flum DR. Routine leak testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program. ACTA ACUST UNITED AC 2012; 147:345-51. [PMID: 22508778 DOI: 10.1001/archsurg.2012.12] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. DESIGN Observational, prospectively designed cohort study. SETTING Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP). PATIENTS Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. INTERVENTIONS Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter. MAIN OUTCOME MEASURE Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. RESULTS Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). CONCLUSION Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.
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Affiliation(s)
- Steve Kwon
- University of Washington, Department of Surgery and Surgical Outcomes Research Center, Seattle, WA 98195, USA
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Endoscopic intraoperative anastomotic testing may avoid early gastrointestinal anastomotic complications. A prospective study. J Gastrointest Surg 2011; 15:145-52. [PMID: 21061182 DOI: 10.1007/s11605-010-1371-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 10/19/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastrointestinal anastomotic complications represent serious events; methods to evaluate anastomotic integrity seem to be suboptimal. Since endoscopic intraoperative anastomotic testing allows direct visualization of anastomosis, complication rates may be theoretically reduced by the use of this technique. METHODS A prospective study involving 118 consecutive oncologic patients undergoing endoscopically tested gastrointestinal stapled anastomoses was carried out. As controls, 148 historical patients without anastomotic testing were used for comparisons. RESULTS In the study group, anastomotic testing revealed 16 defects: 11 (9.3%) air leaks and five (4.3%) bleeding anastomoses. All leaks were oversewn and secured. Bleeding anastomoses were managed under direct visualization, and one non-patent anastomosis was redone. Forty-one (15.4%) postoperative anastomotic complications were observed: eight (3%) bleeding anastomoses, seven (2.6%) stenoses, and 26 (9.8%) clinical leaks. No early dehiscence or bleeding occurred if anastomoses were intraoperatively checked, while these complications were significantly more frequent in non-checked anastomoses (6.1% and 5.4%, respectively). Conversely, late leak and stenosis rates were similar between the two groups. CONCLUSION Endoscopic anastomotic testing was a safe and reliable method to assess integrity of gastrointestinal anastomoses, to correct any defect under direct visualization, and to avoid early complications. However, this method seemed inadequate to predict late anastomotic complications.
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Alaedeen D, Madan AK, Ro CY, Khan KA, Martinez JM, Tichansky DS. Intraoperative Endoscopy and Leaks after Laparoscopic Roux-en-Y Gastric Bypass. Am Surg 2009. [DOI: 10.1177/000313480907500606] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postoperative leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) are a source of morbidity and mortality. Any intervention that would decrease leak rates after LRYGB would be useful. This investigation tested the hypothesis that postoperative leak rates are lower after LRYGB with the routine use of intraoperative endoscopy (EN). Consecutive patients who underwent LRYGB were included. Intraoperative leak testing with air and methylene blue through an orogastric tube (OG) was used in the first 200 patients. Intraoperative endoscopy was used after the first 200 patients. There were 400 patients in this study. Preoperative demographics did not differ between groups. The intraoperative leak rate of the EN group was double the OG group (8 vs 4%; P = not significant), although the difference was not statistically significant. The OG group had a postoperative leak rate of 4 per cent with a mortality rate of 1 per cent. The EN group had a postoperative leak rate of 0.5 per cent with a mortality rate of 0 per cent. The difference in leak rates was statistically significant ( P < 0.04). Despite the issues of learning curve, EN demonstrates more intraoperative leaks than OG, indicating EN may be a more sensitive test than OG. Routine use of EN is associated with less postoperative leaks after LRYGB.
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Affiliation(s)
- Diya Alaedeen
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Atul K. Madan
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Charles Y. Ro
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Khurram A. Khan
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - Jose M. Martinez
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
- Colorado Springs Health Partners, Colorado Springs, Colorado
| | - David S. Tichansky
- Division of Minimally Invasive and Bariatric Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Colorado Springs Health Partners, Colorado Springs, Colorado
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Hydrogen leak test is minimally invasive and highly specific for assessment of the integrity of the luminal closure after natural orifice transluminal endoscopic surgery procedures (with video). Gastrointest Endosc 2009; 69:554-60. [PMID: 19231499 DOI: 10.1016/j.gie.2008.09.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 09/24/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Leak-resistant closure of transluminal access is a major challenge facing natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE To evaluate a hydrogen (H(2))-based leak test for assessment of transluminal-access closure integrity after NOTES procedures. SETTING Nine acute porcine experiments. DESIGN AND INTERVENTION After gastric-wall puncture and balloon dilation, peritoneoscopy was performed, followed by transmural closure of the gastric opening. The animals were randomly assigned to complete or incomplete closure groups. The H(2) leak test was performed by using 1000 mL of 4% H(2) gas mixture and the Hydrogen Leak Detector H2000+. The animals were then euthanized for a methylene blue (MB) test of gastric closure integrity. MAIN OUTCOME MEASUREMENT Intraperitoneal H(2) concentration after gastric insufflation with H(2). RESULTS The H(2) leak test was quick and easy. Intraperitoneal H(2) concentrations in parts per million in both groups were similar at baseline (mean +/- SD, 0.18 +/- 0.29 parts per million [ppm] vs 0.22 +/- 0.35 ppm, P = .97) and after balloon dilation (414.8 +/- 198.5 ppm vs 601.3 +/- 116.1 ppm, P > .99). Postclosure intraperitoneal H(2) concentrations dropped to 0.01 +/- 0.77 ppm in the complete-closure group, similar (P = .81) to matched-pairs preopening levels and significantly lower than in the incomplete-closure group (162.0 +/- 83.0 ppm, P < .02). On necropsy, the MB test was negative in all 5 animals of the complete-closure group and positive in all 4 animals of the incomplete-closure group. A cutoff of 25 ppm in intraperitoneal H(2) concentration after closure gave 100% sensitivity, specificity, and positive and negative predictive values for MB leakage. LIMITATIONS Nonsurvival animal experiments. CONCLUSIONS The H(2) leak test is highly accurate for detection of leakage after NOTES procedures and could become a substitute for currently used MB leak tests.
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Kozol RA, Hyman N, Strong S, Whelan RL, Cha C, Longo WE. Minimizing risk in colon and rectal surgery. Am J Surg 2007; 194:576-87. [PMID: 17936417 DOI: 10.1016/j.amjsurg.2007.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 08/07/2007] [Indexed: 01/11/2023]
Affiliation(s)
- Robert A Kozol
- Department of Surgery, University of Connecticut School of Medicine, 236 Farmington Ave, Farmington, CT 06030, USA
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